Can I take fenofibrate with elevated liver enzymes, specifically in the context of hypertransaminasemia (elevated liver enzymes)?

From the Guidelines

Fenofibrate should not be initiated in patients with significantly elevated liver enzymes, as it may worsen liver function, and alternative treatments should be considered. When considering fenofibrate therapy, it is crucial to evaluate the risk-benefit ratio, especially in patients with pre-existing liver disease or elevated liver enzymes 1. According to the 2013 ACC/AHA guideline on the treatment of blood cholesterol, while there is no direct recommendation against using fenofibrate with elevated liver enzymes, the guideline does emphasize the importance of monitoring liver function when using certain lipid-lowering therapies 1.

Key Considerations

• Baseline liver function tests should be performed before starting fenofibrate, and these tests should be monitored periodically during treatment 1.
• Fenofibrate is metabolized by the liver, and impaired liver function can affect how the drug is processed, potentially leading to increased side effects or complications.
• The decision to use fenofibrate in patients with elevated liver enzymes should be made on a case-by-case basis, considering the degree of liver enzyme elevation and the patient's overall medical profile 1.
• Alternative treatments for managing lipid levels should be considered in patients with significantly elevated liver enzymes or pre-existing liver disease.

Monitoring and Dose Adjustment

• If fenofibrate is prescribed, liver function should be closely monitored, especially in the first year of treatment 1.
• The dose of fenofibrate may need to be adjusted based on the patient's renal status, as fenofibrate should not be used in patients with moderate or severe renal impairment 1.

From the FDA Drug Label

Fenofibrate is contraindicated in patients with active liver disease, including those with primary biliary cirrhosis and unexplained persistent liver function abnormalities [see Contraindications (4)]. Monitor patient’s liver function including serum ALT, AST and total bilirubin, at baseline and periodically for the duration of therapy with fenofibrate Discontinue fenofibrate if signs or symptoms of liver injury develop or if elevated enzyme levels persist (ALT or AST > 3 times the upper limit of normal, or if accompanied by elevation of bilirubin).

Fenofibrate should not be used with elevated liver enzymes. The drug label recommends monitoring liver function at baseline and periodically during therapy, and discontinuing fenofibrate if signs or symptoms of liver injury develop or if elevated enzyme levels persist. 2

From the Research

Elevated Liver Enzymes and Fenofibrate

• Elevated liver enzymes are a common finding in both symptomatic and asymptomatic patients, and can be caused by various factors such as viral hepatitis, genetic liver diseases, drug-induced liver diseases, and cholestatic liver diseases 3.
• There is no direct evidence in the provided studies that specifically addresses the use of fenofibrate with elevated liver enzymes.
• However, studies have shown that statins, which are also lipid-lowering medications like fenofibrate, can be used in patients with elevated liver tests, and may even have a beneficial therapeutic effect in treating the underlying liver disease 4.
• The approach to evaluating elevated liver enzymes should be guided by both the clinical presentation and the pattern of injury, and may involve extensive or focused testing strategies 5, 6, 7.
• In general, the evaluation of elevated liver enzymes should be deliberate and focused, taking into account pre-test probabilities and prior evaluations performed 7.

Considerations for Fenofibrate Use

• While there is no direct evidence on the use of fenofibrate with elevated liver enzymes, it is likely that the decision to use fenofibrate in such cases would depend on the underlying cause of the elevated liver enzymes and the patient's overall clinical presentation.
• As with any medication, the potential benefits and risks of using fenofibrate in patients with elevated liver enzymes should be carefully considered, and patients should be monitored closely for any signs of liver injury or other adverse effects.
• It is recommended to consult with a healthcare professional for personalized advice on the use of fenofibrate with elevated liver enzymes.